A pregnant woman with a chronic heart condition pleaded for doctors to abort her baby so she could live - but both she and her newborn son died.

Her "tragic" story resulted in a year-long investigation by Health and Disability Commissioner Ron Paterson after her family complained about how she was treated. His report, released yesterday, criticises poor communication between clinicians during the woman's pregnancy and a 15-week delay in assessment for a heart condition - 15 times longer than recommended.

The family of the woman and her son did not want them named.

Paterson refused to say which hospital provided "suboptimal" care but the Sunday Star-Times understands Wellington Hospital, one of two hospitals involved, was found to have twice breached the patient code of conduct.

Paterson said: "In my view, her care was jeopardised by the failure of the clinical teams to plan and co-ordinate her treatment. Corporate responsibility for this failure lies with... (Capital and Coast District Health Board)."

Wellington Hospital refused to comment on Paterson's findings or detail what processes have changed since.

The woman's family complained after the 2004 deaths, saying she wanted a termination due to her heart condition but was advised the health risk of her pregnancy was small or that it was too late for a legal termination.

"They stated that Ms B `did not want to be an incubator' and had wanted the baby to take his own chances. They added that she did not believe that she would survive the pregnancy and wanted it terminated to give her the opportunity to live." The woman's baby was delivered stillborn by caesarean at 30 weeks' gestation. She died four hours later. Her sister said the family believed the woman's wishes were over-ridden. Paterson said the woman was not adequately informed of two options - termination of the pregnancy or having heart surgery earlier.

"The tragedy of this case is compounded by the fact that, had Ms B been provided with full and timely information, she may have survived."

The woman had heart surgery to replace an aortic valve in 1997 and had a son in 1999. When she became pregnant again in 2004 she was referred to a cardiac team at Wellington Hospital but was not seen until 21 weeks' gestation when she learned the valve had narrowed.

Obstetric expert Dr Lesley McCowan advised Paterson the maternal foetal medical team should have been consulted semi-urgently to establish an ongoing management plan for the woman's "very high risk pregnancy". She also said the woman's GP, midwife and obstetrician should have ensured she received a proper cardiac assessment in her first trimester.

"There was a whole cascade of events which began early in pregnancy and contributed to the tragic outcome in this very complex case."

In his advice, cardiologist Dr Ian Crozier said a legal termination was an option. He raised concerns about the 15-week delay in the first cardiac review, given ministry guidelines were a week's wait for pregnant women with heart disease.

In Paterson's report, Capital and Coast DHB apologised, and said cardiology and materno-fetal processes had changed to ensure pregnant women with heart conditions were seen urgently.

Paterson planned to tell the ministry about Crozier's concerns that no NZ cardiac unit saw people within its recommended guidelines.